Lisa Dust Ferris State University School of Nursing NURS 341 Newborn Assessment

Newborn Physical Assessment Please use the following code:

+ = Present/normal

= Not present

NA = Not applicable

Admission data (This will be obtained from the babys chart!): Temp: 36.6 HR:152 Resp: 44 Bld glucose: NA APGAR Score 1 min: 8 5 min: 9 Resuscitation measures: Delayed cord clamping, Suction

Bulb, Tactile stimulation, skin to skin when stable and through first feed Ilotycin: 1730 (time) Vit K: 1730 (time) Nursed in L&D: Y N
After you have read the infants chart and gathered the information, give your assessment of this infants status when it was 1 hour after birth (give details, not good)

Length: 50.8cm (20.0in) Wt.: 3650g

HR: 126, R:44, T:36.9 at one hour after birth. The lungs were clear bilaterally, the color was consistent with race and there are no positive findings among respiratory, cardiac, neurology, or skin. The anterior fontanel was soft, flat and approximated. Infant aroused easily with care, lusty cry, positive spontaneous flexion and extension of all limbs. Heart rate consistent with regular rhythm. Skin dry and intact, no eye drainage, no lesions or abrasions, no bruises or edema, color was consistent over whole body and baby was pink and warm. NOW YOU ARE READY TO DO A PHYSICAL ASSESSMEDNT ON THIS BABY (to be completed by you the day you are caring for the baby): Temp: 36.8 HR: 128 Resp: 34 Color: Pink: + Jaundice: Skin: Clear: + Ecchymosis: Rash: Pale: Stained: Mottles: Acrocyanosis: Abrasions: Dry: Milia: Retracting: Mongolian spots: Abdominal: Nevi: Plethoric:

Pressure marks: Petechiae: Lanugo: Vernix: Grunting:

Respirations: Regular: +

Shallow:

Nasal flaring: Shrill:

Sighing:

Other: NA

Cry: Lusty: + Weak: Head: Symmetry/shape: +/ Caput succedaneum: Anterior fontanel: Flat: + Posterior fontanel: Flat: + Sutures Coronal: Sagittal: Overriding

Molding: ISE mark: Full: Full: Separated

Cephalhematoma: Other: NA Depressed: Depressed: Approximated + + +

Lambdoidal:

Ears: (describe exact location & how you determined if it was normal) Position: Normal: + Skin tags: Nose: Symmetry: +/ midline Flaring: Patent: Left: + Right: + Abnormal: Describe normal position: laterally located midline

between top of head and chin; top of ears are level with corners of the eyes

Eyes: eyes were level and aligned with each other, pupils were large, blue in color, light colored eye brows, eye lashes present and even bilaterally, conjunctiva clear, sclera clear, eyes bilaterally reactive to PERRLA, no abrasions on eyelids, red reflex present, eyes open spontaneously to activity, speech and touch, Right Subconjunctive hemorrhage Nevi on lids Edema Red reflex Other Mouth: Mucous membranes: Pink: + Teeth: Epsteins pearls: Abnormal: NA Abnormal: NA Symmetry: +/ midline + NA Pale: Left + NA Cyanotic:

Hard palate: Intact: + Soft palate: Intact: + Lips: Cleft: Drooping:

Anterior chest: Symmetrical: + Clavicles: Intact: + Fracture:

Shape:

Breasts: Palpable tissue: + Heart sound: RRR: +

Engorgement:

Other: NA

Genitals: Voided: Date: 09/14/13 Time:0240

Color of urine: Light yellow

Male: Urethral orifice: Normal position: NA Abnormal (describe): NA Testes (#/location): NA Scrotum: NA Pendulous: NA Rugated: NA Other: NA Partially covers minora: Hymenal tag:

Female: Labia majora: Completely covers : + Labia minora protruding: Posterior: Pilonidal dimple: Spinal column: Symmetry: + Anal patency: Y N Vaginal discharge:

Truft of hair: Intact: +

Stool: Y N Type: Meconium Protruding base:

Anterior Abd: Symmetry: + Other: NA Cord: # of vessels: 3 Extremities: Right Symmetry Movement Digits (number) Flexion creases Palmar creases Sole creases Hips: Intact Right Left + + Dislocated/subluxation Lethargic: + + 5 + + + Left + + 5 + + +

Neuro-muscular: Tone: Normal: +

Rigid: Reflexes: Reflex: Describe what you observed Rooting:

Tremors:

Describe the procedures

Describe normal responses

Touch side of babys mouth Newborn turned towards with index finger finger Baby sucks cheeks inward and puckers lips Newborn throw arms upward and form c shape with hands

Sucking:

Placed gloved finger in mouth of newborn

Moro:

Placed stethoscope on babys chest to assess HR

Stepping:

Pick up baby and barely touch feet to hard surface

Newborn picked up feet in a marching manner Newborn wrapped their fingers around mine Newborn curled toes down over finger

Grasp/hand:

Placed finger in hand of newborn

Grasp/foot:

Placed finger on bottom of newborn foot below toes

What is your overall assessment and prognosis for this infant (do not say good): Overall the infant was doing well and a healthy baby. The vital signs were within normal limits for a newborn and the infant was not struggling to breathe or move. The skin was pink, warm, dry and intact, no rash, lesions, or bruises noted. The head was round with fontanels both anterior and posterior approximated and flat, hair texture was fine and color brown. Eye color blue, red reflex positive bilaterally, no conjunctival hemorrhage or discharge noted. Eyes symmetrical bilaterally, lens clear bilaterally, PERRLA bilaterally. Nose was midline, no drainage noted, nostrils patent bilaterally. Ear cartilage fully developed bilaterally, auricle normal, ear position normal and symmetrical bilaterally, no skin tags noted. Palate in mouth intact, no teeth noted, tongue midline and pink, uvula midline. Chest symmetrical bilaterally, clavicles intact. No grunting, nasal flaring, or retractions noted, regular rhythm and depth of respirations. Abdomen soft, round, 3 umbilical vessels, no hernias noted. Labia majora completely covers minora, no

vaginal discharge or abnormalities in voiding noted. Anus patent, no abnormalities in stooling noted. All extremities are symmetrical, full ROM, 5 digits per each hand and foot, palmar creases normal. No sacral dimple or scoliosis noted.

On the basis of your assessment, list at least TWO nursing diagnosis for this baby and all the teaching interventions you would use for each nursing diagnosis. Please include the rationale for your actions. You must have at least two references besides your textbooks for your rationales. Be sure your assessment and interventions correspond to your Nursing Diagnosis.

Nursing Diagnosis
Ineffective breastfeeding related to maternal anxiety as evidence by the mother stating the baby was not latching on fully.

Necessary Assessments/Interventions
Lactation consultant, give support to the mother, promote comfort and relaxation of mother to decrease pain/anxiety

Rationale
According to an article published in Maternal Child Health Journal, support early on is crucial to allow for breastfeeding to continue successfully, proper resources and education help to encourage the mother to maintain breastfeeding (Cross-Barnet, Augustyn, Gross, Resnik, & Paige, 2012).

Ineffective thermoregulation related to immaturity as evidence by temperature of newborn outside of normal range.

Temperature and vital signs every hour, keep the room at 72 degrees Fahrenheit, use immersion baths (tub bathing)

According to an article published in the Journal of Obstetric, Gynecologic & Neonatal Nursing , immersion baths improve thermoregulation for term and preterm infants when coupled with neonatal skin care guidelines, which include limiting bath time to 10 minutes, regulating water temperature, depth, and wrapping baby in pre-warmed blankets (Loring et al., 2012).

References: Cross-Barnet, C., Augustyn, M., Gross, S., Resnik, A., Paige, D. (2012). Long-term breastfeeding support: failing mothers in need. Maternal Child Health Journal, 16, 19261932. doi: 10.1007/s10995-011-0939-x Loring, C., Gregory, K., Gargan, B., LeBlanc, V., Lundgren, D., Reilly, J., Stobo, K., Walker, C., Zaya, C. (2012). Tub bathing improves thermoregulation of the late preterm infant. Journal of Obstetric, Gynecologic & Neonatal Nursing, 41, 171-179. doi: 10.1111/j.1552-6909.2011.01332.x